Toddlers with massive lower GI bleeding

Prepared by...................Nuthapong Ukarapol, M.D.

Clinical Data
 
CASE #1
CASE #2
Age
2.5 years
1.5 years
Sex
Male
Male
History The patient presented with a 2-day history of moderate amount of fresh blood per rectum. He denied history of fever, abdominal pain, and vomiting. He had been admitted for two units of PRC transfusion at a primary care hospital before referral to our institute. The lowerest hematocrit level was 18%. The patient presented with a history of two episodes of massive lower GI bleeding. He denied abdominal pain, NSAIDs use, and vomiting. The lowerest hematocrit level was 21%; in which one unit of PRC was transfused before referral to our institute.
Examination Mild pallor and melena were noted during digital examination, whereas otherwise was normal. Apparently normal exam.
Question 1: What is the differential diagnosis?
The differential diagnosis of lower GI bleeding in childhood period include:

Infectious causes
Meckel's diverticulum
Intussusception
Intestinal polyps
Henoch-Schonlein purpura
Intestinal volvulus
Intestinal duplication
Inflammatory bowel diseases
Vascular anomalies
Hemorrhoids
Bleeding diathesis

Question 2: What is the investigation of choice?

Because the present two patients had painless massive lower gastrointestinal hemorrhage, the differential diagnosis were limitted to Meckel's diverticulum, intestinal duplication, autoamputated colorectal polyps, inflammatory bowel diseases, vascular anomalies, and bleeding diathesis. Thus, the first line investigation should be Meckel's scan. If it was negative, colonoscopy and coagulation studies would be the next step investigations.
Clinical course and progression
Case #1: At that time, the radionuclear scan was out of order, therefore colonoscopy was initially performed. Large amount of melena and clot blood occupied the entire colon, as a result the scope could be only passed up to the level of 50 cm from the anal verge. The uncovered colonic mucosa, however, appeared normal. The patient underwent exploratory laparotomy, later on. A Meckel's diverticulum was noted at the terminal ileum (Figure1-2). Ileal resection was performed.

Case #2: The Meckel's scan (Tc 99m pertechnetate scintiscan) was carried out with a positive result (Figure 3). An exploratory laparotomy was performed, in which the Meckel's diverticulum was resected.
Figure 1: The operative finding shows Meckel's diverticulum at the ileum.
Figure 2 (left): There is an ulcer leading to gastrointestinal bleeding noted at the base of the diverticulum.
Figure 3 (right): A Meckel's scan shows a small ectopic gastric mucosa noted at the right upper quadrant, representing Meckel's diverticulum. The uptake noted in the picture above and below the Meckel's diverticulum are the stomach and excreted tracer in the urinary bladder, respectively.
Meckel's diverticulum
The development of Meckel's diverticulum results from incomplete regression of the vitelline duct, occuring during the 5-9 weeks gestation. It was firstly described by Ruysch in 1730. The prevalence is approximately 2 % in general population with male predominance (2:1). Forty per cent of the cases will become symptomatic, in which a three-quarter of them, clinical presentations develop within the first two years of life. The most common manifestation is painless massive lower gastrointestinal hemorrhage, followed by inflammation and intestinal obstruction. Twenty-five per cent of the cases contains ectopic gastric mucosa; thereby predisposing to the development of peptic ulcer at the base of the diverticulum, consequently causing GI bleeding. Preoperative resuscitation is very important because the patient commonly develops hypovolemic shock and anemia. The Meckel's scan is the first line investigation in suspected cases; however, a false negative result can present in a patient who has no ectopic gastric mucosa, full bladder, and active bleeding.
The mechanisms of intestinal obstruction include 1) volvulus around a fibrous vitelline band, 2) aberrant branch of primary vitelline artery, 3) development of intussusception leaded by Meckel's diverticulum, and 4) external compression by a large vitelline duct cyst.
Suggested readings:
1. Vane DW, West KW, Grosfeld JL. Vitelline duct anomalies: experience with 217 childhood cases. Arch Surg 1987:122:542-7.
2. Squires Jr RH. Approach to the child with upper and lower gastrointestinal bleeding. In Rudolph AM, editor: Rudolph's Pediatrics. 20th ed.:Appleton&Lange, 1996; 1041-4.
3. Perrault JF, Berry R. Gastrointestinal bleeding. In Walker WA, editor: Pediatric gastrointestinal disease: pathophysiology, diagnosis, management. 2nd ed. St. Louis: Mosby, 1996;323-42.
4. Silber G. Lower gastrointestinal bleeding. Pediatr Rev 1990;12:85-93.
5. Leung AK, Wong AL. Lower gastrointestinal bleeding in children. Pediatr Emerg Care 2002;18:319-23.
Diagnosis : Meckel's diverticulum

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